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HomeMy WebLinkAbout1377A 1378A (7) � .., -, � � ) ;WORKERS'COMPENSATION,DECLARATION . . _ � �: � I. . '�� I hereby affirm�hoi I have a cerlifi[ale of consent to self _ - A P P L I CAT I O N� ��'��R� B U I L D I N G P E RMI T insyre,or a cer�ificate of Workers'Compens�ion Insurance,or � a tertified copy rheregf(Sec.3800,tob.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY Policyl�Io�G�'S7 Company��1� �'��,!%+'�� .. . �. O Cenif�ed copy is hereby furnished. � FOR APPLICANT TO FILL IN nooaess y0� ��-'� -C�� � Certified copy is filed with the county buildl g inspec- BUR�ING /' / tian deportment. � AD�RESS 4/1/SL i , L'"L'���r� S(� !R/ S LOCnuTr ..c��..r�v � . .. !1 JA��n NEAREST 'Date ���_ -� PPlim�� 'L�" — �iTY�6J �.�� �Rn 2 zia .. .. � . � ceosssr. �.-� � . 'CERTIfICATE OF EXEMPTION ROM WORKERS' NO.OF BLDGS. ASSESSOR " - / � COMPENSATION INSl1RANCE � 512E OF LOT NOW ON LOT MAP 600K PAGE ARCEL �.(This section need not be compleled if the permit is(or one TRACT S'7C Z BLOCK lOT NO. USE 7AN� OP /� _3� . hundred dollars(5100)or less.) � -. �/ ��� ' y. OWNER +O(�L��L�S���nl TEL. SPECIAL ' y s y.�r�No. Pe:?�/SCG CONDIT�ON$ I tenify��hot in tha performance of the work for which this � 0 �permit is issued,I shall nol employ any person in any manner � �� • DiSiaKT GROUP TYPE FIRE PRpCE55ED BY �J ' so as to becoma subject fo the Workeri Compensation Laws. ADDRESS %'.�/J1J�/� 1` �d O CONST. 20NE /JQ,, � .. . . . � � �� / H"a-ttlit� � � Oate � Applicanl ' ��T v - Z�P S7ATISTICAL CLASSiFICATION APT. CONDO. V 'NOTICE TO APPLICANT: If, bfter making this Certificate Of "' ARCNRECT O��� �.,- � 1' � 7E11 f - _ . �f - . W Exemption, you sho�ld betome s�bject to fhe-Workeri ENGINEER !2 E�� � �'YJ NO.C `1� CL455 NO. ✓ DWELL.UNITS � p, Compensotion prpvis�ons of thw Lobor Code,you musr forth• qpp��u 7/�G /7S�cL'(/ A i1� SEWER MAP ' Z with comply with s�th provisions or thfs permi� sholl be �+ deemedrevoked. � . CONranCtOfCt6 1=` ..�� r`'v� NO.L7�J�a^�( BK. PG, VALI�ATION , LICENSED CONTRACTORS DECIARATION� i�C._ I hereby affirm thal I am licensed ander provisions of Chapler 9 .. ADORESS j�J �•2 C' NO 7 G•C+�3�' . VALUATION (commencing wiih Section 7000)of Division 3 oi the Businessond f _� Professions Code,ond my license is in fui�force and effecl. _ CI�V ![� f(���✓�� QA55 �� 3 f (�'T'f/ . � � -�, //� J �' SQ.F�.I NO.OF NO.OF CHECK � - . Lifens Nu b r-� �4�rJ� Lic.Class�s SIiE S�S~I� STORIES FAMILIES ONE � , �j�� � . ❑ S Conlr '�� /" " — ��'Date ��•J���� � DESCRIPTION OF WORK NEW � a ezempt from the licensing requirements as I am a .StU Kh�y/ �`V l S�/J A�� � ' �� 3�'7 a , � lice sed architect or a registered professionol engineer.,_.__ ,_ __ _ AIiER ❑ DAT 2 � # 2� acting in my professional capatity (Section 7051, � � � � �'� � . REPAIR � Business and Professions Code). USE OF r FINA � � • •6�`Z$ E%iSTING BLDG. ,J�J I1 V � �EMOL ❑ Lic.or Reg.No. Dale /+PPtKANTt7 �f Te�. �+ e'' � 6 3 2 8 c=.i - OWNER-BUIIDER DECIARATION '� � -(PRiNiI�SC' tI/�C 5�'�'NO.�'I�C�j^;L• �� � I hereby oNirm that I om exempi from the CoMractori License '•�'��� '1�+�F�.�� ��L (V� y -G �.C��[/ •�JG�� . 0 1.2 9—8 2 � . Law for the following reason(Section 7031.5,Business and ADORe55 J� / � ,/ � Professions Code): � � � HkESEtvi �� �,,�1.G.r�-c-C-• .O . . . BIIILDING . . . - - � I, as owner of fhe properfy, or my empioyees wifh AD�RESS � woges as their sole tompensolion,will da fhe work and >'JR i � the strocture is not imended or offered ior sole(Section� ' �«A��T� - -- - . � , ' �,�'��'i'K-�V � 7044,Business and Prafessions CodeJ. , MOVING 7EL. � . � � � ��L3 'O I,a5 owner of ihe prOperty,om ez[IUSIveIy ConhOCiing-' CONTRACTOR� NO. � � � wirh licensed contracrors ro construct the project(Sec- qoDRE55 � � � tion 7044,Business and Professions Code). -� - � �-' ' ' /�� S� RE�UIRED TOTAL SETBAIX FROM EXIST. ' CONSTRUCTION LENDING AGENCY � SET BACK YARD HWY PROP.LINE WIDTH � � I heieby afkrm rhat ihere is a constrocrion lending agency for � feONl ' �' -- � - '� the performonce of 1he work for which this permil is issued p L - � /��l'���y (Sec.3097,Civ.C.l. . . . .. � SiDE � -- ' ' � , P.l. .. . . . . . . lender's Nome /, /� 1 �/ . , . " , � � Lender's Address � � P.C.Fee S Y 3.�J perm�r Fee �✓�L��/ ' � � - I ceriify ihat I have read this opplicotian ond eroie�hot the Issuance Fee ��� � _ obove informotion is correcl.I ogree�o tomply wi�h all Couniy _. invesugai�on Fee .. . . . , . . . � . �. ordinantes a Sto1e laws reloting to building conslruUion, Tmal fee /42��� ' � � ond hereby u o�ize represen�aiives of�his Coonty to emer ' �vp e a ove-me ioned praperty(or inspecfion porpose5. . � � i �J'�y— `. SEE REVERSE FOR EXPIANATORY LANGUAGE � � � 5 . �ura ol Appl�conr or Agem Do�e � . � �'� .. � w .1 • - . � O � . .n �S,' S � A � =nn O p � � � r n�p m a � cL. O .T . � � a ° o f9 � ° � � % O �• p ' -n T . ?r' � ,^�O .�i�`. �'. � p ,'�O .', y p r- p y O p C, v O- m �• � Q� �' � � p ¢ Q • q�_ 7- y ` o � � '� n 3 m c 7 7 S O W �e �7 a � �. 0 m 'CZ O � 3 ~ � r . 10 ^� � � Q � o RD, o � „��n T� ' , r �� 7 . Nr -C n � �7 0 , ' Z x 4v f9 ' p C ... 4 p ^ 3 . � ' 'p •'� a- � . � � w - m � ° n`. 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